Cardiac MRI Findings in Male Patients with Acute Myocarditis in the Presence or Absence of COVID-19 Vaccination

By comparing phenotypic clinical characteristics and cardiovascular MRI findings in 14 patients with mRNA COVID-19 vaccine–associated myocarditis to those in 14 patients with acute myocarditis from other causes, we found that patients with COVID-19 vaccination–associated acute myocarditis have higher left ventricular ejection fraction, higher left ventricular global circumferential and radial strain, and less involvement of late gadolinium enhancement in the septal segments with less involvement of midmyocardial pattern of late gadolinium enhancement, compared with patients with acute myocarditis from other causes.

Cardiovascular magnetic resonance findings in young adult patients with acute myocarditis following mRNA COVID-19 vaccination: a case series

BACKGROUND

Messenger RNA (mRNA) coronavirus disease of 2019 (COVID-19) vaccine are known to cause minor side effects at the injection site and mild global systemic symptoms in first 24-48 h. Recently published case series have reported a possible association between acute myocarditis and COVID-19 vaccination, predominantly in young males.

METHODS

We report a case series of 5 young male patients with cardiovascular magnetic resonance (CMR)-confirmed acute myocarditis within 72 h after receiving a dose of an mRNA-based COVID-19 vaccine.

RESULTS

Our case series suggests that myocarditis in this setting is characterized by myocardial edema and late gadolinium enhancement in the lateral wall of the left ventricular (LV) myocardium, reduced global LV longitudinal strain, and preserved LV ejection fraction. All patients in our series remained clinically stable during a relatively short inpatient hospital stay.

CONCLUSIONS

In conjunction with other recently published case series and national vaccine safety surveillance data, this case series suggests a possible association between acute myocarditis and COVID-19 vaccination in young males and highlights a potential pattern in accompanying CMR abnormalities.

Demographic Pattern and Mortality Risk Factors for Prescription Opioid Overdose Hospitalizations: Results From Nationwide Inpatient Sample Analysis

Objectives To explore the demographic patterns of hospitalizations related to prescription opioid overdose (POD) and evaluate the mortality risk of association in POD inpatients. Methodology We conducted a cross-sectional study using the Nationwide Inpatient Sample of 184,711 POD inpatients. A binomial logistic regression model was used to evaluate the odds ratio (OR) of association for mortality risk due to comorbidities (substance use disorders (SUD) and medical complications) in POD inpatients. Results POD inpatients were majorly females (54.1%), older adults aged 51-75 years (48.5%), whites (81.5%), and from lower household income quartet (32.8%). The most prevalent comorbid SUD among POD inpatients was alcohol (15.7%), followed by cannabis (5.7%), cocaine (4.2%), and amphetamine (1.8%). Comorbid alcohol use disorders had a minimally increased association with mortality but were not statistically significant (OR = 1.036; P = 0.438). POD in patients with cardiac arrest had the highest risk of mortality (OR = 103.423; P < 0.001), followed by shock (OR = 15.367; P < 0.001), coma (OR = 13.427; P < 0.001), and respiratory failure (OR = 12.051; P < 0.001). Conclusions Our study indicates that the hospitalizations related to POD were more prevalent among females, elders between 51 and 75 years of age, whites, and those in the lower household income quartet. The prevalence of prescription opioid use and the hospitalization related to POD remains a significant public health issue. POD inpatients with medical complications were at a higher risk of mortality than with comorbid SUD.

Serial sodium values and adverse outcomes in heart failure with preserved ejection fraction

OBJECTIVE

The purpose of our study is to examine whether serial measurements of serum sodium values after diagnosis identify a higher-risk subset of patients with heart failure with preserved ejection fraction.

METHODS

We identified 50,932 subjects with HFpEF with 759,577 recorded sNa measurements (mean age 72 ± 11 years) using a validated algorithm in the VA national database from 2002 to 2012. We examined the association of repeated measures of sNa with mortality using a multivariable Cox proportional hazards model.

RESULTS

After a median follow-up of 2.9 years (IQR: 1.2-5.4), 19,011 deaths occurred. After adjusting for age, sex, race, BMI, glomerular filtration rate, potassium, coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation, pulmonary disease, diabetes, anemia, and medications, we found J-shaped associations of serum sodium with mortality. HRs for all-cause mortality were 2.48 (95% CI: 2.38-2.60) for the sNA 115.00-133.99 category; and 1.40 (95% CI: 1.35-1.46) for the sNA 143.00-175.00 category compared to the 137.01-140.99 category (ref). We used generalized estimating equation-based negative binomial regression to compute the incidence density ratios (IDR) to examine days hospitalized for heart failure and for all causes. There were a total of 1,275,614 days of all-cause hospitalization and 104,006 days of heart-failure hospitalization. The IDRs for the lowest sNA group were 2.03 (95% CI: 1.90-2.18) for all-cause hospitalization and 1.73 (95% CI: 1.39-2.16) for heart-failure hospitalization.

CONCLUSIONS

Our findings suggest that monitoring of serum sodium values during longitudinal follow-up can identify HFpEF patients at risk of adverse outcomes.

Development and validation of a heart failure with preserved ejection fraction cohort using electronic medical records

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) comprises nearly half of prevalent HF, yet is challenging to curate in a large database of electronic medical records (EMR) since it requires both accurate HF diagnosis and left ventricular ejection fraction (EF) values to be consistently ≥50%.

Methods

We used the national Veterans Affairs EMR to curate a cohort of HFpEF patients from 2002 to 2014. EF values were extracted from clinical documents utilizing natural language processing and an iterative approach was used to refine the algorithm for verification of clinical HFpEF. The final algorithm utilized the following inclusion criteria: any International Classification of Diseases-9 (ICD-9) code of HF (428.xx); all recorded EF ≥50%; and either B-type natriuretic peptide (BNP) or aminoterminal pro-BNP (NT-proBNP) values recorded OR diuretic use within one month of diagnosis of HF. Validation of the algorithm was performed by 3 independent reviewers doing manual chart review of 100 HFpEF cases and 100 controls.

Results

We established a HFpEF cohort of 80,248 patients (out of a total 1,155,376 patients with the ICD-9 diagnosis of HF). Mean age was 72 years; 96% were males and 12% were African-Americans. Validation analysis of the HFpEF algorithm had a sensitivity of 88%, specificity of 96%, positive predictive value of 96%, and a negative predictive value of 87% to identify HFpEF cases.

Conclusion

We developed a sensitive, highly specific algorithm for detecting HFpEF in a large national database. This approach may be applicable to other large EMR databases to identify HFpEF patients.

Prognostic Significance of Baseline Serum Sodium in Heart Failure With Preserved Ejection Fraction

BACKGROUND

The purpose of this study was to evaluate the relationship between serum sodium at the time of diagnosis and long term clinical outcomes in a large national cohort of patients with heart failure with preserved ejection fraction.

METHODS AND RESULTS

We studied 25 440 patients with heart failure with preserved ejection fraction treated at Veterans Affairs medical centers across the United States between 2002 and 2012. Serum sodium at the time of heart failure diagnosis was analyzed as a continuous variable and in categories as follows: low (115.00-134.99 mmol/L), low-normal (135.00-137.99 mmol/L), referent group (138.00-140.99 mmol/L), high normal (141.00-143.99 mmol/L), and high (144.00-160.00 mmol/L). Multivariable Cox regression and negative binomial regression were performed to estimate hazard ratios (95% confidence interval [CI]) and incidence density ratios (95% CI) for the associations of serum sodium with mortality and hospitalizations (heart failure and all-cause), respectively. The average age of patients was 70.8 years, 96.2% were male, and 14% were black. Compared with the referent group, low, low-normal, and high sodium values were associated with 36% (95% CI, 28%-44%), 6% (95% CI, 1%-12%), and 9% (95% CI, 1%-17%) higher risk of all-cause mortality, respectively. Low and low-normal serum sodium were associated with 48% (95% CI, 10%-100%) and 38% (95% CI, 8%-77%) higher risk of number of days of heart failure hospitalizations per year, and with 44% (95% CI, 32%-56%) and 18% (95% CI, 10%-27%) higher risk of number of days of all-cause hospitalizations per year, respectively.

CONCLUSIONS

Both elevated and reduced serum sodium, including values currently considered within normal range, are associated with adverse outcomes in patients with heart failure with preserved ejection fraction.

Retinopathy predicts progression of fasting plasma glucose: An Early Diabetes Intervention Program (EDIP) analysis

BACKGROUND

Retinopathy is increasingly recognized in prediabetic populations, and may herald increased risk of metabolic worsening. The Early Diabetes Intervention Program (EDIP) evaluated worsening of glycemia in screen-detected Type 2 diabetes, following participants for up to 5years. Here we have evaluated whether the presence of retinopathy at the time of detection of diabetes was associated with accelerated progression of glycemia.

METHODS

We prospectively studied 194 participants from EDIP with available baseline retinal photographs. Retinopathy was determined at baseline using 7-field fundus photography and defined as an Early Treatment of Diabetic Retinopathy Study Scale grading score of ≥20.

RESULTS

At baseline, 12% of participants had classical retinal lesions indicating retinopathy. In univariate Cox proportional hazard analysis, the presence of retinopathy at baseline was associated with a doubled risk of progression of fasting plasma glucose (HR 2.02; 95% CI 1.05-3.89). The retinopathy effect was robust to individual adjustment for age and glucose, the most potent determinants of progression in EDIP.

CONCLUSION

Retinopathy was associated with increased risk of progression of fasting plasma glucose among adults with screen-detected, early diabetes. Early detection of retinopathy may help individualize more aggressive therapy to prevent progressive metabolic worsening in early diabetes.

Coffee consumption and calcified atherosclerotic plaques in the coronary arteries: The NHLBI Family Heart Study

BACKGROUND & AIMS

While a recent meta-analysis of prospective studies reported that coffee consumption is associated with a lower risk of cardiovascular disease mortality, limited and inconsistent data are available on the relation of coffee intake with subclinical disease. Thus, the aim of the present study was to see the association of coffee consumption with the prevalence of atherosclerotic plaque in the coronary arteries in NHLBI Family Heart Study.

METHODS

In a cross-sectional design, we studied 1929 participants of the NHLBI Family Heart Study without known coronary heart disease. Coffee consumption was assessed by a semi-quantitative food frequency questionnaire and coronary-artery calcium (CAC) was measured by cardiac computed tomography. We defined prevalent CAC as an Agatston score of ≥100 and used generalized estimating equations to calculate prevalence ratios of CAC as well as a sensitivity analysis at a range of cutpoints for CAC.

RESULTS

Mean age was 56.7 years and 59% of the study subjects were female. In adjusted analysis for age, sex, BMI, smoking, alcohol, physical activity, field center, and energy intake, prevalence ratio (95% CI) for CAC was 1.0 (reference), 0.92 (0.57-1.49), 1.34 (0.86-2.08), 1.30 (0.84-2.02), and 0.99 (0.60-1.64) for coffee consumption of almost never, <1/day, 1/day, 2-3/day, and ≥4 cups/day, respectively. In a sensitivity analysis, there was no evidence of association between coffee consumption and prevalent CAC when CAC cut points of 0, 50, 150, 200, and 300 were used.

CONCLUSIONS

These data do not provide evidence for an association between coffee consumption and prevalent CAC in adult men and women.

Changes in Weight and Glucose Can Protect Against Progression in Early Diabetes Independent of Improvements in β-Cell Function

CONTEXT

Evidence-based strategies to prevent progression of dysglycemia in newly diagnosed type 2 diabetes are needed.

OBJECTIVE

To undertake a secondary analysis of the Early Diabetes Intervention Program (EDIP) in order to understand the features that were protective against worsening glycemia.

DESIGN

EDIP was a randomized, placebo-controlled trial.

SETTING

Two university diabetes centers.

PATIENTS

A total of 219 overweight individuals with fasting glucose < 7.8 mmol/L and 2-hour oral glucose tolerance test (OGTT) glucose > 11.1 mmol/L.

INTERVENTIONS

Acarbose versus placebo, on a background of dietary recommendations, with quarterly visits to assess glycemia and intervention adherence for up to 5 years.

MAIN OUTCOME MEASURES

Progression of fasting glucose ≥ 7.8 mmol/L on two consecutive quarterly visits. Cox proportional hazards modeling and ANOVA were performed to evaluate determinants of progression.

RESULTS

Progression-free status was associated with reductions in weight, fasting glucose, 2-hour OGTT glucose, and increases in the high-density lipoprotein/triglyceride ratio. The reduction in fasting glucose was the only effect that remained significantly associated with progression-free status in multivariable Cox modeling. The reduction in fasting glucose was in turn primarily associated with reductions in weight and in 2-hour OGTT glucose. Acarbose treatment did not explain these changes.

CONCLUSIONS

In early diabetes, reductions in glucose, driven by reductions in weight, can delay progressive metabolic worsening. These observations underscore the importance of lifestyle management including weight loss as a tool to mitigate worsening of glycemia in newly diagnosed diabetes.

Profound defects in β-cell function in screen-detected type 2 diabetes are not improved with glucose-lowering treatment in the Early Diabetes Intervention Program (EDIP)

BACKGROUND

Few studies have measured the ability of interventions to affect declining β-cell function in screen-detected type 2 diabetes. The Early Diabetes Intervention Programme (ClinicalTrials.gov NCT01470937) was a randomized study based on the hypothesis that improving postprandial glucose excursions with acarbose would slow the progression of fasting hyperglycaemia in screen-detected type 2 diabetes. In the Early Diabetes Intervention Programme, the effect of acarbose plus lifestyle advice on progression of fasting hyperglycaemia over a 5-year period was not greater than that of placebo. However, there was an early glucose-lowering effect of the trial. The objective of the current secondary analysis was to describe β-cell function changes in response to glucose lowering.

METHODS

Participants were overweight adult subjects with screen-detected type 2 diabetes. β-cell function was measured using hyperglycaemic clamps and oral glucose tolerance testing. The primary outcome was the change in β-cell function from baseline to year 1, the time point where the maximal glucose-lowering effect was seen.

RESULTS

At baseline, participants exhibited markedly impaired first-phase insulin response. Despite significant reductions in weight, fasting plasma glucose (PG) and 2-h PG, there was no clinically significant improvement in the first-phase insulin response. Late-phase insulin responses declined despite beneficial glycaemic effects of interventions.

CONCLUSIONS

Insulin secretion is already severely impaired in early, screen-detected type 2 diabetes. Effective glucose-lowering intervention with acarbose was not sufficient to improve insulin secretion or halt the decline of β-cell function.

Effect of acarbose to delay progression of carotid intima-media thickness in early diabetes

BACKGROUND

The anti-diabetic agent acarbose reduces postprandial glucose excursions. We have evaluated the effect of randomized treatment with acarbose on the progression of carotid intima-media thickness (IMT) in early diabetes.

METHODS

The Early Diabetes Intervention Program was a randomized trial of acarbose versus placebo in 219 participants with early diabetes characterized by glucose values over 11.1 mmol/L 2 h after a 75 g oral glucose load and a mean HbA1c of 6.3%. IMT was measured at baseline and yearly. Follow-up was discontinued if participants progressed to the study glucose endpoints; IMT readings were available for a median of 2 years, with 72 subjects followed for 5 years.

RESULTS

Progressive increases in IMT were seen in both treatment groups, but progression was reduced in participants randomized to acarbose (p = 0.047). In age, sex and smoking-adjusted analyses, IMT progression was associated with greater fasting and oral glucose tolerance test-excursion glucose, fasting insulin, cholesterol and glycated low-density lipoprotein concentrations. IMT progression was reduced with study-related changes in weight, insulin and non-esterified fatty acids; these features were more strongly associated with reduced IMT progression than acarbose treatment. Despite strong associations of baseline glycemia with IMT progression, study-related changes in glucose were not important determinants of IMT progression.

CONCLUSIONS

Acarbose can delay progression of carotid intima-media thickness in early diabetes defined by an oral glucose tolerance test. Glucose, weight, insulin and lipids contributed to risk of progression but reductions in glycemia were not major determinants of reduced rate of IMT progression. Vascular benefits of acarbose may be independent of its glycemic effects.

Effect of Graduated Compression Stockings on Venous Blood Velocity in Supine Resting Hospitalized Patients

The effects of graduated compression stockings (GCSs) on venous blood velocity were measured in 26 hospitalized medical patients while supine at rest. Peak blood velocity in the right femoral vein was 21.6 cm/s without GCS and 23.0 cm/s with GCS [not significant (NS)]. Peak blood velocity in the right popliteal vein was 12.5 cm/s without GCS and 15.0 cm/s with GCS (NS). Mean blood velocity in the right femoral vein did not increase significantly with GCS, but mean blood velocity in the right popliteal vein increased marginally from 5.0 cm/s to 5.8 cm/s ( P = .05). Among 11 patients with venous insufficiency (refilling time ≤19 s), neither peak nor mean blood velocity in the femoral or popliteal veins increased significantly with GCS. In conclusion, thigh-length GCS in hospitalized patients had little or no effect on popliteal or femoral vein blood velocity while supine at rest, irrespective of whether the patients had venous insufficiency.

A matched case control study in veteran patients with high cardiovascular risk (CVR) examining cardiac medication (CMed) prescribing differences between prostate cancer (PC) patients on androgen deprivation therapy (ADT) and men without PC

e15179

Background: Conflicting reports exist on associations between ADT and CVR in PC patients (pts). The current study tests the hypothesis that underutilization of CMeds in PC pts with known CVR contributes to their increased cardiac event rates. Methods: Veteran men without malignancy (no-PC, controls) and men with PC on ADT (cases) were consented through the IUSCC IRB-approved biorepository protocol. All pts had high CVR defined as the presence of > 2 of the following: age > 45, Body mass index (BMI) > 30 kg/m2, hypertension (HTN), hyperlipidemia (HL), diabetes (DM), and smoking history (SmHx). Prior coronary artery disease (CAD) qualified pts as severe CVR. Each case was matched with 2 controls in the following order of priority: prior CAD, HTN, DM, HL, SmHx, age, BMI, and race. CMeds prescriptions included in the table below were verified via VAMC pharmacy records. CMeds prescription differences between cases and controls were tested by one-sided chi-Squared testing for each medication and by logistic regression for different classes of medications. Results: Between 1/2007 and 6/2011, 53 cases and 254 controls were enrolled in the IUSCC VAMC clinics. After 2:1 matching, the final cohort included 53 cases and 106 controls. Demographics included: prior CAD – 27%, HTN – 60%, DM – 31%, HL – 40%, SmHx – 63%, BMI – median 29.7 kg/m2, Age – median 66 yrs. Controls were younger than cases (71.4 yrs cases – 63.1 yrs controls, p<0.0001). No statistically significant differences in CMed prescribing frequency were observed between the two groups. Conclusions: Differences in CMed prescribing practices between PC pts and no-PC men with high CVR is not a factor contributing to increased cardiac events in PC pts on ADT in our Veteran population. The study size warrants confirmation in a larger dataset. [Table: see text]

Successful recruitment of healthy African American men to genomic studies from high-volume community health fairs: implications for future genomic research in minority populations

BACKGROUND

Study of genomic data obtained from patient biospecimens is frequent in research of subjects with prostate and other epithelial malignancies. Understanding of the characteristics of healthy men who participate in genomic research is limited.

METHODS

Patients were identified through the Prostate Cancer Genetic Risk Evaluation of SNPs Study and the Indiana University Cancer Biomarker Study, 2 population-based biomarker and cohort studies. Between 2006 and 2010, healthy Caucasian (n = 774) and healthy African American (n = 381) men were recruited and enrolled at high-volume free community health fairs. Each participant completed a demographic questionnaire and provided a blood sample for genomic research investigations. Frequency differences between demographic features of healthy African American and Caucasian men were compared and analyzed by 2-sample t test and multivariate logistic regression after adjusting potential confounding variables with significance at the P < .05 level. Features examined included: age, body mass index (BMI), income, education, marital status, tobacco, alcohol, family history, prostate-specific antigen (PSA) level, and prior prostate cancer screening history.

RESULTS

Significant differences between healthy Caucasian and African American men participating in genomic research included: marital status (married, 69% Caucasian vs 46% African American, P< < .001), mean age (years, 58 Caucasian vs 54 African American, P < .001), mean BMI (kg/m(2), 30.9 Caucasian vs 32.3 African American, P = .004), annual income (P = .038), education (P = .002), and mean PSA (ng/mL, 1.2 Caucasian vs 2.0 African American, P = .005).

CONCLUSIONS

Significant demographic differences exist between healthy Caucasian and African American men choosing to participate in genomic research. These differences may be important in designing genomic research study recruitment strategies.

Flexible bronchoscopy as a diagnostic tool in the evaluation of pulmonary tuberculosis in an elderly population

OBJECTIVE

This study intends to determine what role fiberoptic bronchoscopy (FOB) plays in the diagnosis of tuberculosis (TB), particularly in a geriatric population.

DESIGN

Cases of tuberculosis reported to the Tennessee Department of Health during the years 1989 and 1990 were divided into two age groups: Group A (< 65 years) and Group B (> or = 65 years). Natural sputum smears and cultures positive for M. tuberculosis (M. TB) in each group were compared with FOB specimens, acid-fast bacilli (AFB) smears and cultures. Data were analyzed by chi-square tests of independence for each year, then compared to determine statistical significance.

SETTING AND PATIENTS

Of the 601 TB cases reported to the State of Tennessee in 1989, 285 patients were in Group A and 316 in Group B. For 1990, 525 cases were reported, 269 in Group A and 256 in Group B. All cases met CDC-approved criteria for diagnosis of tuberculosis.

MEASUREMENTS

The number of positive AFB smears and M. TB cultures were compared in each group. In cases with sputum negative but FOB specimens positive for TB, identification was made by FOB only.

MAIN RESULTS

In Group A, 26 (9.1%) were diagnosed by FOB; only eight of these had positive sputum cultures. In Group B, 77 (24.4%) were diagnosed by FOB. Of these, 23 had positive sputum cultures; the remaining 54 patients (17.1%) had diagnoses based on FOB alone. In 1990, 269 cases of TB were reported in Group A. Of these, 38 (14.1%) were diagnosed by FOB. There were 256 TB cases reported among Group B, 83 (32.4%) of which were diagnosed by FOB. Of these 83 cases, 60 (23.4%) were diagnosed by FOB only. While no statistically significant difference was seen between the 1989 and 1990 rates of TB diagnosis by FOB for those in Group A (age < 65), the difference in rates for those in Group B (age > or = 65) was statistically significant (P < 0.05).

CONCLUSIONS

A steady increase in the use of FOB as a diagnostic tool was noted, suggesting that a significant number (19.9%) of geriatric TB cases might have been missed without the aid of FOB. While the exact reason for its increased utilization is not known, this study indicates that FOB has become a more important source of diagnosis in pulmonary TB, particularly among the elderly.